He noted that the longer a company operates the more commitments it inevitably makes to its various stakeholders (customers, vendors, employees, partners). As these commitments pile up it becomes more difficult for the company to adapt to changing market conditions (to stay ahead of disruptors, respond to changing customer tastes, pursue new product opportunities, etc.). At the extreme, the company becomes virtually paralyzed and unable to innovate.

This is a much more accurate explanation of why it's difficult for big companies to innovate than the old notion that these companies get successful and turn incompetent or arrogant. To the contrary, they're actually quite competent and humble -- they're simply trying to honor the commitments they've made to various stakeholders over the years. On the surface this is a good thing. But when you look more closely you see that companies will eventually become nothing but a product of their past commitments made at a different time by different people with a different context. Stagnation is inevitable.

This point really resonated with me. Whenever I speak to a job candidate that's working with a company that's struggling they almost always explain the company's problem as some version of the 'commitment problem'. There's a great lesson in here for startups. When a startup finds itself making painful decisions only to honor past commitments, it's worth pausing and ensuring that those commitments are consistent with what's needed in the moment and what's best for the company in the long-term. Unraveling commitments that were made in the early days can be extremely challenging, especially for startups that rely on their early customers to fuel growth. But at scale too many commitments will lead to a stale product for everyone that's made by a company that may not be around for too long.

I’ve written quite a bit about the topic of creating a sense of urgency in a sales process. See here, here and here. This is an enormously important issue for high growth startups as the timing of when sales will close impacts, among other things, investor expectations and perception, salesforce efficiency, financial performance, cash management and when sales commissions are paid. Sales pipeline review meetings often include more discussion about when specific deals will close as opposed to if specific deals will close.

Before any discussion of creating urgency can happen, two things must occur: 1.) the seller must understand the buyer's priorities and how those priorities line up (or don't line up) with the seller's product and 2.) the seller must have a detailed understanding of the buyer's buying process and all of the stakeholders that need to be involved in getting a deal to closure. Once these things are understood, sellers can begin to think about how to create urgency and shorten the length of a sales cycle.

Good sales organizations will use a variety of tactics to accelerate a sales process; from the use of detailed ROI documents to help the buyer prioritize one project over another to offering discounts in return for a speedier close. There’s really no end to the number of tactics that can be used to create urgency and more predictable sales results. I’ve created the framework below to help sales organizations brainstorm solutions to this problem and come up with new tactics.

Here's how to think about the framework. On the X-axis are seller focused versus buyer focused urgency tactics. In most cases, a seller wants to align urgency with what’s important to the buyer. That is, the seller wants to help the buyer understand the cost of the problem of not having the seller’s product and quantify the impact of not having that product. Good sellers will frequently remind the buyer of the value being missed by not having the product in place. It’s also ideal for the seller to line up a close date with a particular event that's important to the buyer (e.g. a life insurance seller lining up their close date with the buyer’s benefits open enrollment period). These are generally the most effective ways to drive urgency.

That said, while a seller always wants a buyer to be moving fast because it’s inherently good for the buyer, this doesn’t always have to be the case. The seller and buyer are on an equal playing field. The seller may have reasons why they want to move a deal faster than the buyer. Obviously, in some cases, the buyer may not care about the seller's priorities but I would encourage sellers to be transparent about them anyway. Recently, a salesperson was trying to sell me more software for my sales team and he told me he’d give me a substantial discount if I bought sooner rather than later. I asked him why he would sacrifice a lot of revenue for an earlier close and he was very transparent about the fact that his company's fiscal quarter was coming to a close and they had a revenue number to hit. As the buyer, I genuinely appreciated this transparency and he was able to get his sale. I don't support the use of tricks or dishonesty to get sellers buy quickly, but I absolutely support sellers being extremely transparent about their priorities.

The Y-axis outlines qualitative versus quantitative tactics.

Quantitative tactics are those tactics that are driven by a financial impact to the seller or the buyer. On the buyer side this is the revenue that will be gained or the costs that will be reduced from buying the product; e.g. every day that goes by that the product isn’t in place the buyer is losing X dollars. On the seller side, this is about the value to the seller that comes if the deal closes sooner rather than later. This can be the ability for the seller to use idle resources, or the importance of hitting a sales target, or simply the fact that revenue today is worth more than revenue tomorrow.

Qualitative tactics, on the other hand, are more art than science. These are things like the quality of the relationship between the buyer and the seller, the emotional components of the product (e.g. the seller will 'look good' to certain stakeholders if they buy) and the fact that a competitor is using the product and the buyer is not. Qualitative urgency is fun to talk about because it’s a place where sellers can get really, really creative.

Two final thoughts:

First, there are dozens of hooks that will drive urgency within this framework. Those listed above aren't appropriate for every organization. And when brainstorming it's important to get multiple stakeholders involved to come up with as many hooks as possible. Many of them may be totally unique to an individual organization.

Finally, I generally believe that sellers want to spend most of their time focused on the top-right quadrant. Ultimately, quantifiable, buyer-focused value is the most scalable and sustainable way for an organization to grow. But it doesn’t work every time on every deal. Selling into large organizations can get incredibly complex. The best sellers combat complexity with creativity. I hope the framework above helps sales organizations do just that.

Sales commission plans are a crucial part of a company's sales organization. They can be really complicated and difficult to get right. And for earlier stage companies they'll often change quite frequently. Managing this change can be really difficult as a sales leader has to balance several different components and several different stakeholders. Because of that, I think it's important to have a set of principles that guide the formation of your commission plan. I recently put these down on paper and thought I'd share them here.

Commission plans should value and prioritize impact over individual compensation. While the best reps should be very highly paid, the goal of the plan is to benefit the entire organization as opposed to individual reps.

Potential earnings from commissions should be competitive+ and commission should be a large percentage of overall compensation. The percentage will vary depending on the role in the organization. The closer the individual is to the actual transaction the higher the percent of compensation will come from commission.

Commissions should be paid out to reps quickly to ensure that they can easily connect the value they've added to the business with the financial reward they receive.

The plan should employ things like clawbacks and true-ups/down to reduce risk to the company when paying commissions ahead of cash collection.

The plan should include consequences for customer churn and incentivize high-quality sales and smooth hand-offs.

The plan should be fair so that there's an equal playing field across territories and customer segments.

The plan should be iterative and updated regularly to ensure that it remains competitive and consistent with the principles above.

The 'daily deal’ boom and bust, if nothing else, taught us that consumers will respond to incentives. Deep, short-term discounts are extremely effective with consumers because the consumer generally has full autonomy and decision making authority to make the purchase.

This is not true in enterprise sales. When a seller offers a large enterprise an incentive if they agree to buy on a certain date, the work has only just begun.

I’ve written in the past that, very often, the most difficult part of an enterprise sale isn’t getting an enterprise to buy, it’s getting the enterprise to buy now, or to buy on the seller’s timeline.

To help with this, here are four questions a seller can ask themselves to be sure that the incentive they’re offering is going to work:

Does the buyer believe in the incentive? Gimmicks don’t scale. Incentives must be legitimate and make sense. There are all kinds of legitimate reasons why a seller wants a buyer to buy sooner rather than later. The seller should communicate these legitimate hooks to the buyer in a sincere and logical way. If it doesn’t make sense to the buyer then they won’t respect the seller’s timeline.

Does the buyer care about the incentive? Incentives that sound great to the seller may not always sound great to the buyer. Sellers should take the time to dig in and discover how impactful the incentive is to the buyer. It's helpful to say something like, “if this deal closes by the end of the quarter I can offer you a 20% price reduction. I understand that it may be challenging to move this through your process on such a short timeline, so is this something that’s important enough to you to accelerate this deal?"

Does the buyer understand their own buying process? A buyer’s job most likely is not to buy things. They have their own set of priorities to worry about and they may have no idea what it takes to get a contract signed within their own organization. It’s hard for big companies to buy things. Sellers should be aware of this and push their buyer to be sure they understand their own buying process. A buyer can’t agree to buy on a seller’s timeline if they don’t understand what it takes.

Does the buyer have the capability to drive their own buying process and stick to the seller's timeline? While buying decisions are often made at the top, the actual execution of the ‘buy’ often happens at lower levels. Sellers must make sure that the individual that is agreeing to the incentive has the authority to drive the accelerated timeline.

Of course, sellers should always strive to have their product’s core value proposition line up with their buyer's problems to create inherent urgency. But in many cases an incentive may help. Sellers should answer the questions above before they get comfortable that the incentive they’re offering is going to accelerate the deal.

Back in 2012 I wrote about the 'bottom-up' approach to enterprise software distribution. Bottom-up happens when a product is initially procured by an individual employee or group of employees and then, once a critical mass is reached, a seller upsells the product across the organization with additional features, bulk pricing, etc. This has now become a mainstream approach to enterprise software distribution. I recently attended a Go-to market conference held by a prominent venture capital firm and they advised everyone that the first question an enterprise startup should ask before designing a go-to market strategy is: are you bottom-up or top-down?

With successes like Atlassian and Slack and others the bottom-up model has come a long, long way in recent years.

However, bottom-up doesn't work for every industry -- at least right now. Take healthcare as an example. To sell a product into a large healthcare organization you must get IT approval, work with compliance, promote workflow changes, train staff, potentially integrate into an EHR, address HIPPA concerns and do lots of other stuff before the first user can log-in. The top-down model can be a requirement.

That said, I believe we’ll start to see this change. The bottom-up model will only become more mainstream and will take market share from vendors that don’t adapt. Traditional enterprise vendors should take note and start to evolve.

Some specific implications:

Software vendors need to prioritize the user of their product over the buyer of their product (they're quickly becoming the same person). Engagement and user satisfaction metrics should be equally important as sales metrics. Employees are increasingly demanding that the software they use at work function at an equivalent level to the apps they use on their phone. And switching from vendor to vendor continues to get easier. If a product isn't adored by its users its ripe for disruption.

This change also means that product must play a much larger role in distribution. The product must be remarkable so people will talk to their colleagues about it and it must be easy to spread the word about and nearly effortless to access. If you look at the fastest growing enterprise startups (see below) the one thing you’ll find is that nearly all of them make it extremely easy for a new user to sign up.

Finally, this trend will bring big changes to sales and marketing teams. Marketing (messaging from one to many) will play a larger role in the selling process as it'll be responsible for acquiring the product's early users. This changes messaging and use of channels in a big way. When any employee within a company is a potential buyer your marketing starts to look a lot more like Apple's than Oracle's. And salespeople will need to increase their selling competence to represent both the user (human factor data insights, workflow changes, usability) as well as the enterprise buyer (product context, integration, ROI).

The line between enterprise software and consumer software is continuing to blur. And while there are industries where top-down will continue to thrive, the processes and systems and beliefs that have enabled this approach are beginning to crumble.

In the end, the real threat that bottom-up startups present to top-down vendors isn't just that they may have a more effective way of getting a product into market, it's that their approach requires them to build something that's very unique in enterprise software: a product that people love.

Perhaps the biggest challenge in enterprise sales is getting a large organization to act and act quickly. Because of size and complexity and bureaucracy it can be very difficult for large organizations to make quick decisions. When an enterprise becomes a certain size it inevitably creates a series of checks and balances to protect its assets and competitive position. This protects shareholders but also makes it difficult to innovate and to make decisions to invest in innovative technologies.

Selling into these organizations requires one to find an external champion that is willing to break through blockers and jump over walls. One of the ways to do this is by helping the buyer see a future positive state. This is what great sellers do. They get a buyer to see a future state that is better than their current state that will require a relatively small investment. If the buyer is rational then they will buy.

Of course it's never that simple.

Over the holidays I had the chance to read Michael Lewis’s new book, The Undoing Project, and it shined some light on some of the many reasons why it's never that simple. The book takes on the issue of “decision theory” and tells the story of two Israeli psychologists and their mission to better understand how the human mind makes decisions. They found that people are absolutely not rational decision makers. I thought I'd capture some of their ideas here.

One of the most interesting ideas discussed in the book is the notion of 'loss aversion'. People will irrationally avoid losing what they have -- even if it could result in a much larger gain. Here's a summary of one their experiments.

When you gave a person a choice between a gift of $500 and a 50-50 shot at winning $1,000, he picked the sure thing. Give that same person a choice between losing $ 500 for sure and a 50-50 risk of losing $1,000, and he took the bet. He became a risk seeker. The odds that people demanded to accept a certain loss over the chance of some greater loss crudely mirrored the odds they demanded to forgo a certain gain for the chance of a greater gain. For example, to get people to prefer a 50-50 chance of $1,000 over some certain gain, you had to lower the certain gain to around $370. To get them to prefer a certain loss to a 50-50 chance of losing $ 1,000, you had to lower the loss to around $370.

This is the reason insurance companies make money. They take margin from our irrationality. For most people, the happiness involved in receiving a desirable object is smaller than the unhappiness involved in losing the same object.

Not only do people act irrationally (from a probability perspective) to avoid loss, they'll also make decisions based on descriptions of probabilities.

Another useful example from the book is a study done with lung cancer patients:

Lung cancer doctors and patients in the early 1980s faced two unequally unpleasant options: surgery or radiation. Surgery was more likely to extend your life, but, unlike radiation, it came with the small risk of instant death. When you told people that they had a 90 percent chance of surviving surgery, 82 percent of patients opted for surgery. But when you told them that they had a 10 percent chance of dying from the surgery — which was of course just a different way of putting the same odds — only 54 percent chose the surgery.

People facing life and death decisions will not respond to probabilities, they will respond to the way probabilities are described to them.

Lastly, the book notes that most people will respond to probabilities using their own context and view of the world, as opposed to the actual probability. Here's a great example.

Ask yourself the following question:

An individual has been described by a neighbor as follows: “Steve is very shy and withdrawn, invariably helpful but with little interest in people or in the world of reality. A meek and tidy soul, he has a need for order and structure, and a passion for detail.” Is Steve more likely to be a librarian or a farmer?

The vast majority of people would say that Steve is a librarian despite the fact that there are 20 times more male farmers in the United States than there are male librarians. People ignore probabilities and give more credence to “resemblance” or context or experience. We don't make rational, probabilistic decisions.

The lessons from all of this for enterprise sellers are simple:

Most buyers will prefer to buy something that will help them avoid loss (keep their job) rather than increase gain (get a promotion). Sellers need to find a way to appeal to loss aversion or find a champion that's willing to take a risk.

Buyers are not buying your product, they are buying your description of your product. The way you explain what you do is incredibly important and needs to be constantly tested and iterated.

Finally, buyers may not make rational buying choices based on the probability of success. They’ll rely on “resemblances” and their own context. They’re more likely to buy the thing that 'feels' like it will be successful than the thing that has the highest probability of creating a positive future state.

What one salesperson defines as a good initial meeting in enterprise sales can often be quite different from another salesperson's definition. This is natural as different people have different perspectives and definitions of success. I've found it useful to standardize the definition of a high quality meeting to remove some of this ambiguity and get everyone aligned on what success means. Here are four simple checks to determine whether or not you had a high quality initial meeting with a prospect.

Did you gain a solid understanding of the customer's buying process (who needs to be involved, where budget comes from, timeline for decisions, potential roadblocks, etc.)?

Did the prospect agree to a short, weekly check-in to keep the buying process on track?

Did you identify an executive sponsor and project lead?

Does the prospect understand and feel some level of urgency to get to closure?

Note that of course you can still have a positive interaction and discussion with a potential customer and not do all of these things. Often it's not appropriate to get through all of this in an initial meeting. But from a pipeline velocity perspective, if you haven't accomplished these four things there's definitely some work to get done.

When sales aren't moving fast enough, the first thing a sales leader should do is look at the sales funnel to identify the bottleneck. Are we not filling the top of the funnel? Are we not converting meetings to proposals? Are we not getting the contract signed quickly enough?

But in some cases the sales funnel might not be granular enough to tell you what's really going on.

With that in mind, I've come up with a set of questions to ask to help you identify trends and areas where things aren't working.

Look across the entire pipeline and ask the questions below about each individual deal. if the answer to any question is 'no' put a checkmark next to the question. If the answer is yes leave it blank. If the question isn't relevant because the deal isn't far enough along in the sales process also leave it blank.

After going through each of these questions for each of your deals you should get a good sense of trends and what's slowing things down and you can now focus on fixing that problem area. Do it again in a month and focus on that newly identified problem area. Repeat.

This is a super simple and quick way to find out what's going on in the funnel. It can be used for an entire team or an individual rep.

Is there adequate top of the funnel activity -- are we working hard?

Are we getting meetings with people we want to meet with?

Do the people we’re talking to have a problem that we’ve diagnosed?

Do the people we're talking to believe that the problem they have is a large and important one?

Do the people we're meeting with have decision making authority?

Is our message (solution) resonating with the people that have the problem?

Is there excitement around moving to a proposal?

Do we have agreement on a proposal?

Are we getting insight into the buying process and the actors that need to be involved in the buying process?

I couldn’t stay up to watch the results come in. I went to sleep around 11pm.
I woke up around 4am and checked my phone and saw a Business Insider alert that said:

“Trump strikes conciliatory tone in victory speech, praises Clinton."

A small bit of light in an enormous amount of dread.

I didn’t sleep much after that. I laid there and felt a weird combination of fear and sadness. But a couple hours later when I went to the gym I started to come around a bit. Here are some of the thoughts that have been rolling through my mind today.

I used to kind of like Donald Trump. I remember listening to him when he would call in to the Don Imus show many years ago. I didn’t know much about him and he was pretty right-leaning on fiscal issues but on the social stuff he was definitely a New Yorker. He was a reasonable guy and made good some good points. And I loved how positive he was. We’ve all been annoyed by his constant use of adjectives like "terrific" and "tremendous" and "unbelievable" but back then I kind of liked it.

Month after month throughout the primary and into the general election everyone laughed at the notion of Donald Trump becoming President. It was a joke. What he pulled off last night was amazing. He brilliantly tapped into a large amount of fear and anger and ignorance and was able to light a fire among a huge number of rural voters.

To light this fire he talked about a ban on Muslims entering the country, reversing Roe v. Wade, repealing Obamacare and building a wall on the Mexican border. I’d be willing to bet that not one of those things will happen. And I’d be willing to bet that Trump doesn’t actually want any of those things to happen. Those issues generated talking points that won him the election. He won. He doesn’t owe anybody any favors and he doesn’t need to do any of that nonsense. If he wants any chance at reelection he’s going to have to come way, way back to the middle.

We need to create a new word and stop using the word “racist”. It’s too strong and inflammatory and in most cases inaccurate. I don’t think Trump is racist and I don’t think most of his supporters are racist. I think they’re ignorant and uninformed and fearful of a changing world but I don’t think they’re racist. When we call them racist it makes thoughtful conversation almost impossible.

Trump is a brilliant marketer and he knows that taglines work. "Make America Great Again" was the perfect tagline for him and it’s a crystal clear indicator of his strategy. When he says this to fearful voters in rural areas what he really means is let’s go back 50 years to a time when the world was less competitive. Where automation wasn’t destroying jobs and we didn’t have to compete globally and you could stay at a job for thirty years and you didn’t need two incomes. We live in a global economy now and those days are over but that vision is incredibly appealing to a lot of people.

The most important political issue to me personally is healthcare. Throughout the campaign Trump has continuously threatened to “Repeal Obamacare!” and has received loud cheers for it. I’ll bet if you asked the people cheering what that actually means most of them would have no idea. Those that do have an idea would probably just assume he’s referring to the mandate. I really doubt that healthcare is going to be high on Trump’s list. The election is over and he doesn’t need the “Obamacare” talking point anymore. Further, there are now 22 million people that have insurance as a result of the Affordable Care Act and that will be difficult for politicians to roll back. A lot of people were angry when Medicare launched but virtually nobody would advocate taking it away. And most of the payment reform has been rolled into a new law called MACRA that is separate from the Affordable Care Act. Healthcare is complicated and for the most part on a good path that should be supported by both parties (if you remove the politics). I don’t see things changing in a material way in the next four years.

You can argue that Trump has no experience but the reality is that Obama didn’t have the greatest experience and that turned out ok. What Obama did in the last two elections was also amazing. I’m a big fan of Obama but he was not the most qualified candidate when we was first elected. The presidency is now a popularity contest. We just have to get used to that.

Having said the above, I think we deserve a president that is prepared and dignified and isn’t reckless. I always thought George W. Bush was in over his head and wasn’t well prepared and was misguided but he didn’t embarrass our country and he wasn’t reckless. This is my main concern with this outcome. Being embarrassed by our President isn’t the end of the world but I do fear his recklessness. The generals should keep him in line when it comes to putting troops on the ground where they don’t belong but his rhetoric clearly can’t be contained. This isn’t about fearing that he has his finger on the button. This is about tiny groups of people all over the world looking for a reason to hate America. There is no worse time in American history in my view to be alienating our enemy. They are inside of our country and outside of our country and they have no home state and no borders and we can never find them all. Reckless, reactive, inflammatory speech from the American president is the most useful recruiting tool that Isis and other terror groups could ever imagine. I fear that he may not be able to rein this in. I truly hope I’m wrong.

As of right now it's being reported that 118 million people voted. Trump got 59 million and Clinton got 59 million. The difference is 0.3 percent. That's just crazy.

Finally, Trump is our President. Obama said this morning that we should all be rooting for Trump now and he’s absolutely right. We may hate everything he says and disagree with everything he says but like it or not he’s our President. As much we don't want to, we have to at least accept that.

In thinking about a product's user acquisition, the nice thing about enterprise products is that when you get one customer you get a lot of users. You just need to sell one CIO on your product and you’ll quickly pick up thousands of users.

The not so nice thing about enterprise is that you’re going to lose about 20% of those users every year due to employee turnover. Your entire user base is going to turn over every five years. Acquisition scales in enterprise. Retention does not.

The not so nice about consumer products is that, unlike enterprise, you have to acquire users one by one. You don’t have the scalable distribution channel that you have with enterprise. In consumer, user acquisition is expensive and really difficult.

But the nice about consumer products is that once you get users you can keep them forever (you don’t have the turnover problem).

It’s interesting to note that some companies have figured out how to take the good from enterprise and the good from consumer.

One example is eShares, an enterprise product that digitizes paper stock certificates and options and warrants and rolls them up into an easy to use cap table to help startups and startup employees manage their equity. Employees generally sign up for the service just before their start date when they receive an option grant from their new company (to sign the option grant employees need an eShares account). If the employee leaves the company they keep their account open to manage their equity and they can add subsequent option grants from subsequent companies to keep all their documents in one place.

eShares is brilliant in that they have morphed an enterprise product into a consumer product and have reaped the benefits of both models. This is a super powerful way to quickly build a huge set of engaged users and is a great way to get ahead and build a platform rather than just a useful app. I’m sure eShares investors are taking note.

Over the weekend I spent some time reviewing the 2015 Medicare Access & CHIP Reauthorization Act final rule (MACRA) that was released by HHS last week.

MACRA was a bi-partisan law focused on the Obama administration’s goal of moving 50% of Medicare payment away from fee-for-service and towards alternative payment models. The final rule lays out details on how the program will work and how clinicians can participate.

For those of you that are new to this stuff, the goal of all of this is to allow clinicians to focus on (and get paid for) the quality of care they provide as opposed to the quantity of care they provide; with a focus on disease prevention and improving coordination between clinicians. This is a major part of how we're going to reduce the $3 trillion cost of healthcare in the U.S.

The overarching set of policies that make up MACRA are referred to as the Quality Payment Program.

The document released by HHS last week that explains all of this is 2,398 pages long though the majority of it is made up of responses to public comments made regarding the proposed rule (you can find a 24 page summary of the document here). The rule will be implemented beginning in January of 2017 and will impact nearly all stakeholders across the healthcare system.

I thought I’d capture some of my notes on the rule here with a particular focus on those things that might matter to digital health companies. If your company is focused on improving outcomes, patient engagement, patient volume, interoperability or care coordination then you should take some time to understand MACRA. Key points from the rule below:

For context, Medicare covers 55 million people and accounts for more than 20% of all U.S. healthcare spend. Medicare’s approach to payment is generally followed by commercial payers — in fact, many of these payers are farther down the road in payment reform than Medicare is at this point.

MACRA is a statement by the government that they are dead serious about paying clinicians for value. If your business relies on a flat fee-for-service model it's time to start thinking hard about how you can get ahead of this change.

Medicare has setup a transition year for the Quality Payment Program (2017), but physicians must act in some form during 2017. If clinicians do nothing in 2017 with regard to the Quality Payment Program, they’ll receive a 4% penalty against their Medicare payments beginning in 2019.

With all of these acronyms the Quality Payment Program can seem confusing. It's really not. There are two simple payment programs that clinicians can participate in: 1. Merit-based Incentive Payment System (MIPS) or 2. Alternative Payment Model (APM) — NextGen ACO, Medicare Shared Savings ACO, etc.

If a clinician is already in an APM nothing will change for them and they'll receive a 5% lump sum incentive payment that will run through 2024 and they can avoid the reporting requirements that will come with MIPS.

Some of the APM options in 2017 will include Comprehensive ESRD (end-stage renal disease), Comprehensive Primary Care (CPC+), Next Generation ACO. Medicare Shared Savings Program - Tracks 2 and 3 (Track 2 allows clinicians to take up to 60% of shared savings; Track 3 - 75%).

If a clinician is not participating in an APM, they can participate in MIPS. MIPS will focus on 3 areas: quality measures, advancing care information and general improvement activities. Medicare has created a nice set of guidelines to help better under the measures associated withe each of these areas. Vendors should take a hard look at these measures as these are major business drivers that non-APM clinicians will be thinking about next year.

The MIPS program allows for more flexibility than previous programs in that clinicians can select their own pace and the amount of data they would like to collect and submit to Medicare. There are three options to participate in MIPS in 2017. 1. Test the program by submitting a minimum amount of quality data. 2. Submit 90 days of 2017 data. 3. Submit a full year of data.

The timeline for implementation looks like this. At some point in 2017, clinicians must collect some amount of performance data and collect data documenting their use of technology and submit that data to Medicare by March of 2018. Medicare will give feedback on that data during the remainder of 2018. If eligible, clinicians will then earn a positive MIPS payment adjustment or APM incentive beginning in January of 2019. The payment adjustment will start at 5% and increase to 9% in 2022.

Medicare is putting aside $100 million to be paid over 5 years to train small practices on the rule.

CMS will also allow “reporting as a group” for clinicians that put themselves under the same tax identification number.

MIPS replaces meaningful use with the "advancing care information" program which speaks to use of technology. This program is focused on only 5 key areas: 1. Security risk analysis, 2. e-prescribing, 3. patient access, 4. summary of care, 5. request/accept summary of care. Again this is a good area for digital health companies to dive in.

The rule is set to be finalized on October 19th.

For the most part, commentators are praising this effort by Medicare. The Quality Payment Program does a nice job of setting up clear objectives for clinicians, with flexible levels of participation and lots of concessions for smaller providers that don't have the infrastructure or resources to facilitate complicated reimbursement activities.

With a new administration coming next year and the inevitable confusion around what will come next, the Quality Payment Program does a nice job of making it much easier for clinicians to embrace those activities that will significantly lower cost and improve quality and ultimately patient health.

Salesforce.com runs the CRM system (Customer Relationship Management) for a huge number of companies — at last check more than 150,000. It’s interesting to think of the number of duplicate records that must exist in Salesforce. As an example, there are probably hundreds of vendors that, as we speak, are trying to sell their product into Microsoft. Each of these vendors has a record (or opportunity) titled, “Microsoft” in their instance of Salesforce.
In many situations, such as sales to a large software company like Microsoft, this redundancy makes sense. Most of the vendors selling to Microsoft are selling very different products to very different stakeholders within the company. So it's logical to have a different record in Salesforce for each sales opportunity.

But for narrow industries like real estate, this redundancy makes no sense at all. As we speak, there are at least ten brokers trying to rent space on the 11th floor of 600 Park Avenue in New York. If all of these brokers use Salesforce.com as their CRM that means there are ten records for only one sales opportunity. Ten brokers would be entering information on the same opportunity in ten different places. This is silly. But this is the way traditional, silo'ed CRM works.

Real estate brokers would benefit immensely from shared records in Salesforce where they all could view the same profile for the same sales opportunity. The opportunity would include the most up to date information on availability, square footage, price per square foot, etc. This would bring 10x more value to Salesforce's customers.

Now consider what's happening in healthcare. The average Medicare patient sees seven providers per year; if the patient has a chronic condition it can be many more than that. These seven providers don’t work together. They’re employed by different organizations, work in different locations and likely use different medical record software. This means that there are seven separate records in seven different places containing seven separate sets of information for only one patient. This isn't just wasteful, it makes it impossible for providers to work together to optimize patient care.

Real estate, healthcare and many other industries need software that doesn't simply get the same job done seven or ten times across disparate organizations but instead brings all of the stakeholders together to use a single, shared record.

Of course there are a number of challenges associated with building this type of networked software -- not the least of which is getting disparate stakeholders to agree to share important information with one another. But I'd guess that a big segment of the next generation of multi-billion enterprise startups will build software around sharing and networks as opposed to silos and features.

Selling an innovative product into a large organization is extremely difficult. The average enterprise sale requires sign off from 5.4 individuals. And when selling something that is novel that the buyer hasn't bought before it can be two or three times that number. In addition, there's no set budget or buying process in place for a buyer to buy. As a result, it falls on the seller to create a process for the buyer to purchase the innovation.
I designed the process below to help address this challenge. The idea is to take the buyer through a set of meetings that generates support for the idea and get an gets them comfortable that they're checking all the boxes they need to check to get a contract signed.

The process requires three meetings (though the second and third meetings could be grouped together for smaller, less complex deals).

The Concept Meeting. This meeting is where the seller introduces the concept, gets support from the buyer that the product solves an important problem and that the seller's product might be a good solution to that problem. The goal for this meeting is to ask for the buyer's permission to start a process around examining the potential ROI of a partnership. If the buyer isn't supportive of the concept, both parties shake hands and part ways.

The Financial Meeting. If the concept meeting is successful, prior to the financial meeting, the seller should ask the buyer to provide them with some financial inputs that will help determine the return on investment that would come from a partnership. The purpose of the financial meeting is to walk through the financial inputs and an ROI model and allow the buyer to poke holes in the model and to get to agreement on what a realistic ROI might be. If the ROI is compelling and the project is worth prioritizing, move to the next meeting. If it's not, shake hands and part ways. The ROI is going to be the thing that drives the rest of the process so it's crucial to have agreement in this area. It's also crucial that, when possible, the seller is using the buyer's own numbers in the model, rather than industry averages.

The Implementation Meeting. The purpose of this meeting is to determine whether or not it makes sense for the buyer to buy the product now. With a compelling ROI, it will most likely make sense, but there are lots other considerations. Technology resources, leadership changes, budget cycles, competing priorities, etc. The idea is to get the prospect so excited about the importance of the problem and the concept and the ROI that all of these concerns will be overcome. But this meeting should be used to put everything on the table. The meeting should include the appropriate stakeholders from both sides to determine if the project can be implemented and, if it can, what kind of work will need to be done and which resources will be required. A timeline with tasks and assigned owners should also be discussed and (ideally) agreed upon. If successful, the next step is to move to contract and setup a weekly meeting between both organizations to track the deal to contract close and product delivery. If that can't be done, both parties should shake hands and part ways. In this meeting the seller should inventory all of the elements of the customer's procurement process and get all of them down on paper. Those elements should be incorporated into a project management document that will be tracked in the weekly meeting.

One other note: when moving the deal to contract, the seller should setup a short meeting with the attorney on the buyer side. Because the product is innovative, the contract terms may be confusing and non-standard. Walking the attorney through the product and the purpose of the partnership should dramatically reduce back and forth on the contract.

Being disciplined about taking the buyer through these three meetings and understanding exactly what they'll need to do be able to write a check will help sellers accelerate sales cycles and avoid many of the pitfalls that come when selling into a large organization.

So often "selling" innovation is the easy part. The bigger challenge, in many cases, is helping the buyer "buy."

A16z had a good podcast the other day talking about startups with network effects and it got me thinking about network effects in enterprise businesses. A product has network effects when the product becomes more valuable as more people use it. Your fax machine was more valuable when more people bought fax machines — you could fax more people. Facebook is more valuable when more of your friends use it -- you can view more photos of your friends.

Businesses with network effects scale exponentially. The reason is that their users effectively become extensions of their sales and marketing team. A Facebook user has an inherent incentive to get other people to use the product. This is a beautiful way to grow and scale a business.

In order to maintain growth, though, these businesses need to ensure that they're retaining the users they acquire -- which is an entirely different challenge. This is relatively easy in B2C because, in theory, the user can be part of the network forever. This is much harder in B2B because users — employees — turnover at the rate of ~20% per year (people get terminated and quit). So in theory, the entire network turns over every five years. And while it's true that often an employee that leaves is replaced by another this kind of churn is not a great way to scale.

That said, some B2B network effect businesses have found ways to retain some users after they change jobs. LinkedIn, Evernote, Wunderlist, Dropbox are a few that come to mind. Not only do these businesses retain their users as they move from job to job, these users also drive new customer acquisition by promoting the product within their new companies (what I refer to as B2E2B). These businesses are seeing network effects drive new users, retention of those users when they move to a new job, and new sales driven by those employees that evangelize the product in their new companies. This how an enterprise business can grow like WhatsApp.

But this isn't easy. Enterprises are concerned about their employees using the same software as they move from company to company -- e.g. they don't want an employee taking their Evernote notes on to their next company. And the product customizations and switching costs may be so high in some cases that the value of the product doesn't translate from one company to another.

The challenges are significant; but the businesses that build an enterprise product with 1.) inherent network effects to drive new users and 2.) the ability for those users to stay engaged with the product as they move from job to job will be the networks that win.

Below is an updated version of a presentation I show to B2B startup teams that are beginning their sales efforts. It's presented here without the context surrounding each of the points but the insights should still be helpful.

Defining the attributes to look for in any new hire is really challenging.

People are complex and every situation and every environment is different. So it's extremely difficult to apply a blanket set of attributes that will lead to success in any job.

I’ve found that this is particularly difficult with “strategic sales” roles in a startup. By strategic sales I mean a role where a salesperson is selling a highly innovative product into a large organization that requires a large investment of time and/or money from that organization.

It’s important to define strategic sales because the skill set required to be able to close strategic deals is very different from the skill set required to close smaller, more defined, "transactional" deals. Often, success in transactional selling comes down to simple hard work and effort. If you analyze a transactional sales funnel you'll see that there actually isn’t a huge difference between conversions for high performing salespeople and conversions for low performing salespeople (by conversions I mean things like 'phone call to meeting set' and 'meeting held to verbal commitment'). Success in that world often comes down to volume. More calls = more sales.

While there’s certainly nothing wrong with good old-fashioned hard work -- in fact, it's a requirement -- strategic sales is almost exactly the opposite of transactional sales. Conversions really matter and lead qualification is even more crucial because strategic deals require a huge time commitment from the salesperson. And there are massive differences between the conversion rates of high-performing salespeople versus low-performing salespeople. A high-performing strategic salesperson can convert 100% of their meetings into an active sales cycle; a low performing strategic salesperson may convert none. Literally zero. Strategic sales is not a numbers game.

Ben Horowitz likes to say that closing a deal with a large organization is like passing a law in congress. And it’s even harder than that when selling innovation — there's no set process for the buyer to buy within their organization or budget to buy the product. And in a startup, you’re small and nobody knows you and you don’t have a clearly defined sales process and you don't have perfectly polished sales materials. It’s really difficult.

I've thought a lot about the attributes that are most closely correlated with success in strategic sales. I've seen a lot of successful strategic salespeople and a lot of unsuccessful strategic salespeople. It's a problem I've been trying to understand for years.

Recently I’ve spoken to a number of people I trust on this topic and here’s where I think I’ve landed. Here are the four key attributes of a successful strategic salesperson.

Insatiable curiosity

In order to solve a complex problem you need to fully understand it. How does the buyer buy? Who has influence in the organization? What value do customers see in the product? What does the customer do during the day? How is the buyer bonused or promoted? What other options does the buyer have?

I could literally write 100 more questions like this. A strategic salesperson must always be wondering about the answers to these questions. They should constantly be learning from their customers, their leadership, their colleagues, the media, their competitors and anyone else that will talk to them. They need to be obsessing about the problem and trying to build a story and a solution and constantly iterating their approach.

A person that doesn’t have this level of insatiable curiosity simply won’t figure it out. They'll get stuck.

Optimistic grit

I’m fusing two attributes together with this one but I think it’s necessary. Any type of sale will inevitably lead to lots of rejection of the salesperson, the product and the company. This sucks. It’s painful. It’s even worse when selling innovation because there will be prospects that think the idea is crazy and will never work and the buyer has no process or defined way to buy the product. In order to get through this the salesperson must be a winner and must have a winning attitude and know that they can overcome. And they must have the grit and determination to keep getting up after they get knocked down. It may sound cliché but it's true. I've never met a pessimist that was good at strategic sales. There will be an endless number of reasons why it won’t work and the only people I’ve seen that will push through have a high level of optimistic grit.

Extreme humility

I used to joke that there are two types of salespeople:

1.) The type of salesperson that flies home from a bad meeting with a prospect and sits on the plane mentally blaming the product, the marketing team, the legal team, their boss or the prospect that just doesn’t “get it."

2.) The salesperson that sits on the plane thinking: How could I have answered that one question better? What else should I add to the presentation? What should I take out? What’s the context of the person that didn’t like the product? Where are they coming from? Does the product I’m selling threaten some of the people in the room? What went well in that meeting and what didn’t go well in that meeting? Who can help me get better?

The second approach requires an immense, almost unnatural level of humility. It’s human nature to point fingers when things don’t go well. It’s also often perfectly reasonable -- because it might actually may be someone else’s fault! But placing energy into #1 is a losing approach. Obsessing about the things that we can control is the way to win. So much energy can be soaked up by complaining and blaming others. Great strategic salespeople transform the energy that most put into complaining and blaming and point it toward improvement.

Ability to educate and inspire

I’ve written before that people buy with their heart and justify it with their mind. This is why I advocate not showing a lot of numbers in an initial sales presentation — the prospect doesn’t know or trust the salesperson yet and they’re generally not buying for ROI anyway. They’re buying because of the way the product makes them feel.

As a result, when selling innovation it’s crucial that the buyer be on board with the salespersons's mission and buy in to their perspective on both the problem they have and the way that the salespersons's company is going about solving that problem. The sale has to be somewhat fun and interesting and educational and insightful. It can’t be boring. I don’t mean that the salesperson has to personally be super charismatic or an amazing presenter (though that helps), I mean that they have to be intelligent and interesting and insightful. The buyer has to want to get behind the company and the product -- they have to become a true advocate.

It's a lot of work for a company to buy something. It requires security reviews, legal reviews, budget reviews, consensus building and many other activities. It also creates a lot of risk for the champion. If they're going to go on the line and buy an innovative product they have to be excited and inspired.

Great strategic salespeople continuously inspire, excite and educate their prospects.

It was nice to see the news a few weeks ago that Massachusetts House Speaker Robert DeLeo vowed to put new limits on contracts that prevent employees from working for competitors.
"Non-competes" that restrict the free movement of talent from one company to another can do real damage to an individual's livelihood and the economy at large. Many people believe that the reason that the explosion of successful tech companies happened in Silicon Valley is because of California's effective ban on employee non-competes. Allowing talent to flow to the best organizations without friction is good for a local economy.

Unfortunately, over the past several months I've seen lots of startups going in the opposite direction by including aggressive non-compete terms in employee agreements.

Many companies take it a step farther and require 'no-poaching' terms in their vendor contracts and even try to collude with other local startups and agree to not steal one another's employees.

I don't think companies fully understand the damage that's being done with these types of arrangements. Let me explain.

Imagine that you're working for a startup in Buffalo, New York (Buffalo actually has a pretty hot startup community by the way). And imagine that there are another 20 tech companies in Buffalo that, at some point, you could go work for -- you have the talent they need and you'd potentially like working for some of these companies. Then imagine that the startup you currently work for requires you to sign a non-compete as part of your employment contract. Then you learn that your company requires all of their vendors and customers and partners to sign an agreement that precludes them from poaching your company's employees.

As your company grows, the number of other companies that can demand your services around your home has dropped from 20 to, say, 12. Suddenly 40% of the companies that would potentially demand your services now can no longer demand your services. So the demand for your services has decreased 40%. You're now 40% less valuable than you used to be.

At a minimum, a company doing this to their employees is unethical. At its worst, it's illegal (Apple, Google, Intel and Adobe recently paid a $415 million fine for colluding on no-poaching efforts to suppress employee wages).

When a company creates an agreement where another company cannot poach its employees, they are artificially reducing the value of those employees and their ability to make a living.

Again, the spirt of this is understandable. Hiring and training employees is expensive and companies want to fight to keep their best people. But addressing employee churn through contracts is a backwards way of handling the problem.

The better (and harder) way of dealing with the problem is to create an environment where good employees feel valued and are being challenged and are working on difficult problems and are developing professionally and personally and are being compensated fairly. Writing contracts to compensate for shortcomings in these areas is cruel and likely very ineffective in the long term. And it's nice to see that the state of Massachusetts is catching on and pushing for legislation that will protect employees and the local economy.

The best way to keep employees loyal is to act in a way that deserves loyalty.

I've added some productivity hacks over the last several months. Here are 5 that have been working well for me lately:

File, Do, Defer. I've started using the "file, do, defer" system. I look at a task (in Wunderlist, a great to-do list manager) or an email in my inbox and decide if it needs action or not. If it doesn’t need action I either delegate it or file it. If it does need action and takes less than 3 minutes, I do it. If it will take more than 3 minutes I’ll defer to a time when I have more bandwidth and focus. To keep me focused on the 3 minute rule I’ve begun using the Pomodoro app for Mac that tracks the time I spend on a task. This isn’t to make me rush through the task it’s to make sure I stay focused on it and get it done quickly and don’t get distracted.

Working Offline. I’ve been doing this for years and can’t recommend it enough. I put my email in offline mode, close Slack and focus on initiating rather than responding.

Virtual Assistant. I’ve hired a virtual assistant for personal tasks. There are lots of great services out there but I use FancyHands which has been great. My virtual assistant does everything for me that I don't want to do -- they have have coordinated my move, found me a couch, helped plan a vacation, changed my cable service, researched health insurance plans and booked a New Year's Eve dinner reservation. I’m constantly scanning my to do list and looking for low-value tasks that I can outsource. It's low cost and a massive time saver.

Soylent. I’ve begun drinking Soylent, a meal replacement drink that supposedly contains every nutrient needed by the human body. It’s fantastic. It allows me to have breakfast on the go and sometimes lunch on the go so I can maintain energy with zero time commitment. It’s incredibly helpful on hectic days.

Make projects seem small. We all have those projects or tasks that need to get done but seem hard and time consuming and stressful and keep getting put off. I read about a productivity trick in the book Getting Things Done to help deal with this problem. The trick is that you think about the thing you need to do that you keep putting off and on the bottom of a piece of paper you write down the outcome that you want with regard to the project -- e.g. what is success? Then break it up until small tasks and write those as a list on the rest of the page. Going through the process of breaking the project into small tasks makes it seem so much easier and actually gets you somewhat excited to go do it.

I had a good conversation the other day with a former colleague who’s considering making a move to very early-stage startup. I shared with him the list of questions I ask myself before I make a commitment to working with a startup and thought I’d share them here as well.

A quick disclaimer: startups are inherently risky and these five questions aren’t designed to help you avoid a high level of risk. That’s not the point. These questions are designed to help ensure that you understand the risk and make you a bit more comfortable that you’re making a good decision.

Here they are:

Do you have confidence in the people, particularly the leadership team? There’s a great quote from Peter Drucker that I can’t seem to find where he points out that, when a company finally succeeds, more often than not, it will find that it will end up selling a different product at a different price to a totally different set of customers than it initially had planned. The point is that the startup doesn’t have to have the perfect idea or the perfect product to be successful. What they have now probably isn’t right. And that’s ok. What’s important is that you’re working with an ultra-talented team that can iterate and execute like crazy. I’ve written before that the most critical traits for people working in startups are grit, humility, curiosity and adaptability. If you find that the team you’re working with has these traits you’re off to a good start.

Has the founder(s) earned the right to know a secret? If what this startup is doing is so valuable, why isn’t someone else doing it? More often than not the reason is that the founder knows something that other people don’t. Or at least knows how to execute in a way that others don’t. It’s important to be able to understand the secret that the startup knows and to understand why they know it and others don't.

Can the investors/board articulate how the business could be massive and why it’s defensible? Prior to making a jump, when possible, it’s important to talk with some of the investors and board members. This is a good way to test their engagement and confidence in the company and alignment with leadership. Really push them on why they invested. Ask them what they think the core of the business will be and what they think will come after the core. If they can’t confidently articulate this in a way that makes sense it’s a clear red flag.

Can you see yourself being truly passionate about the work you'll be doing? Startups are tough. You’re fighting an uphill battle most of the time and there are lots of highs and even more lows (at least at the beginning). If it's easy then it's not valuable. I’ve found that dealing with the pain of working at a startup is a lot easier when I truly believe and care about the mission of the company. If you don't care about the impact you'll have beyond your own personal benefit then you'll find that the tough days are a lot tougher.

What are 3 reasons it could fail? Again, most startups are long shots. And it’s important to be humble enough to know that you can fail. If you can’t articulate 3 reasons that it could fail, then you either don’t understand the business well enough or you aren’t taking the risk very seriously. Do your diligence such that you understand as many risks as possible and the reasons it might not work out. If after truly understanding the risks and potential pitfalls ahead you really feel like you still want to make the move then you've probably found a good fit.

There’s been a lot of talk in the tech blogosphere over the last couple of weeks about the convergence of private and public valuations. One of the things that hasn’t been talked about all that much is how important this convergence is for employees at early-stage companies.
I was talking to a founder recently and he was telling me that he really struggles with the tradeoff between the importance of showing the world that his company has a unicorn-like valuation versus the importance of keeping his valuation low so that new employees can see lots of value in a follow-on round or an IPO.

On one hand, being a unicorn gets you lots of good press and attention and is for good sales and good for recruiting. On the other hand, a huge valuation makes it hard to deliver value to employees in the form of stock options — if you’re already a unicorn, it’s likely that future employees have missed the big uptick and equity becomes a lot less valuable from a compensation perspective. When you have a potential bubble in the private market and normalcy in the public market, lots of employees are going to find their options are deep underwater. Castlight Health learned this the hard way following their IPO last year (see image below).

Because of the emergence of crowdfunding, angel syndicates, private exchanges, and a lower regulatory bar to invest in early-stage startups, it’s likely that we’ll start to see much more consistency between private valuations and subsequent public valuations. Also, don’t underestimate tools like eShares that help founders manage complex cap tables. I can vividly remember being at a startup where we didn’t want to give out stock options to consultants for no other reason than it would’ve added too much complexity to our cap table. It's a lot easier for a private company to manage thousands of investors than it used to be.

A founder’s desire to push for a massive valuation is perfectly understandable. It creates a buzz that helps recruit employees and close big deals. But when founders push too hard for a private valuation that won't hold up when employees find liquidity, it's bad for the team that built the company in the early years. It's great to see private and public valuations beginning to converge.